Thursday, July 4, 2013

Health Disparities Should Be Taken to Heart

We were saddened by the death of actor James Gandolfini who
died of a heart attack on June 19th, 2013. Interestingly, as is sometimes the
case when a celebrity dies, his passing has been used as an opportunity to
teach people about health and disease--in Gandolfini's case heart disease
(think of Rock Hudson and HIV, Bette Davis and breast cancer). In my opinion,
however, a big opportunity to teach about how disease and death really happen
was missed by the coverage, and in one way the coverage was actually harmful.
I'll write about that and what it has to do with public health in Mid-Michigan
below, but first, how has the press covered Gandolfini's heart attack?

Writers like Ken Sepkowitz who wrote about Gandolfini in the
Daily Beast on June 20th, and Maggie Fox writing for NBC on the 21st,
appropriately used his death at the relatively young age of 51 to warn that
heart disease remains the leading cause of death in the United States. As
Sepkowitz wrote:

"The CDC tracks the impact of cardiac disease closely,
and the numbers are staggering. According to their statistics, about 600,000
people in the U.S. die from heart disease each year, meaning heart attacks,
heart failure, rhythm disturbances, and other problems. It’s the nation’s No. 1
killer. Of these deaths, coronary heart disease—the narrowing of the arteries
that feed the heart—accounts for more than half the deaths."

The writers of these articles call for individuals to lead
healthier lifestyles, for more awareness of heart disease, and laud
improvements in medical technology. So, what's wrong with that?

One thing that is wrong is the perpetuation of the myth that
a big killer like heart disease is not really a public health problem, but is
more related to individual choices. It’s the idea that heart disease is
happening because individuals are making "bad choices" and if they'd
just stop it we'd be fine. The reality is that widespread heart disease is the
result of public policies that harm people's health, and the solutions to it
also lie in the public sphere.

Consider this: heart disease mortality rates have been cut
in half in the past 35 years. In the jurisdiction of the Mid-Michigan District
Health Department, heart disease deaths have declined from over 400 per 100,000
people in 1980 to 206 today.* This amazing drop is mostly due to the sharp
decline in smoking--the rate of smoking was also halved during the same period. Significant
reductions in smoking were only achieved after policies were enacted that
prevent people from smoking in public places, workplaces, restaurants and bars.
The other important contributing factor is advances in medicine--if you do get
heart disease you are a lot less likely to die of it today--and these advances are largely the result of public, not private, investments. Thank goodness for
these positive trends since as we know, other risk factors like obesity and
hypertension have been moving in the wrong direction.

The other thing that is wrong is that the coverage continues
to foster the belief that everyone needs to be equally concerned
about heart disease. The reality is that heart disease, like most health
threats, tends to prey on vulnerable, low-income people. Generally speaking, people
of Mr. Gandolfini's stature, and others who are well-off (if not rich), are
comparatively less likely to get heart disease than working class, unemployed,
uninsured people and minorities.

For example, lower income people are twice as likely as
those with higher incomes to be living with heart disease. In Michigan, nearly 7 percent of those with
incomes under $35,000 have been told by a doctor they have heart disease, while
only 3.6 percent of those with incomes over $75,000 have heart disease.

Lower income people tend to have more risk factors for heart
disease. Nearly 40 percent of adults with incomes under $35,000 have been told
they have high blood pressure and 45 percent have high cholesterol. But among
those with incomes over $75,000 only 26 percent have high blood pressure and 36
percent have high cholesterol.

Do low-income people really die at a higher rate from heart
disease? Of course they do, and we see this at the Mid-Michigan District Health
Department. Consider one of our
counties, Clinton County, which is one the state's wealthiest, with an average
household income of over $58,000 dollars per year. Clinton has a very low heart
disease mortality rate, only 181 per 100,000 people. In contrast Gratiot and
Montcalm are lower income counties with household incomes right around $40,000.
The heart disease mortality rate in Gratiot is 244 and it is 204 in Montcalm.

The failure to acknowledge these health disparities makes it
very difficult for people to identify the kinds of actions that are truly
necessary to improve health—actions that would reduce the economic and social inequality
that cause so much poor health in the first place. For example, groups that are
still called “minorities” (although they are majorities in some other parts of
the country), like African Americans, Hispanics and Asians are still in the low
single digits as a percentage of the population in Mid-Michigan. This leads
some to say, “We don’t have diversity here”, or “We don’t have disparity here.”
And if we don’t have diversity or disparity then health problems here must not
be due to inequality, they must be due to “bad choices”. How can Mid-Michigan elected leaders vote
against the expansion of Medicaid to bring relief to their constituents who are
suffering without affordable health care (Courageous Senator Roger Kahn is a
notable exception)? Because, they think, around here we don’t have disparity,
we have people who made bad choices who have to live with the consequences.

But the reality is we DO have disparity in Mid-Michigan: severe,
lingering economic and social inequality that is all the more pernicious
because it is invisible to some of us—invisible even though it is obvious in
the unemployment statistics, the poverty rates and on the faces of our clients
at the Health Department.

The best way writers like Sepkowitz and Fox can help
Americans fight disease and death is to emphasize at every opportunity its economic
and social causes. When we can see the inequality around us, then we’ll be able
to embrace policies, like Medicaid expansion, that can change it.

A happy, healthy Fourth, everyone!

*The data used in this post come from the Michigan
Department of Community Health and can be found at www.michigan.gov/mdch. In
particular look at the Behavioral Risk Factor Survey which has data broken out
by income.

1 comment:

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